HHS Public Access Author manuscript Author Manuscript
JAMA. Author manuscript; available in PMC 2017 October 18. Published in final edited form as: JAMA. 2016 October 18; 316(15): 1595–1597. doi:10.1001/jama.2016.12040.
Longitudinal Evaluation of Work Status and Productivity After Bariatric Surgery
Author Manuscript
Rafael Alfonso-Cristancho, MD, PhD, MSc, Wendy C. King, PhD, James E. Mitchell, MD, Ramesh Ramanathan, MD, Sean D. Sullivan, PhD, Steven H. Belle, PhD, MScHyg, and David R. Flum, MD, MPH University of Washington, Seattle (Alfonso-Cristancho, Sullivan, Flum); University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania (King, Belle); Neuropsychiatric Research Institute, Fargo, North Dakota (Mitchell); University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Ramanathan) Obesity is associated with sick leave, disability, and work place injuries.1,2 Bariatric surgery is an effective treatment for patients with severe obesity.3,4 Evidence is limited regarding the relationship between bariatric surgery and work productivity. We assessed working status and productivity change in the first 3 years following surgery for severe obesity.
Methods Author Manuscript
Adults with severe obesity undergoing bariatric surgery were recruited (February 2005– February 2009) at 10 US centers for the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study.4 Each center obtained institutional review board approval; participants provided written consent. Three-year follow-up through October 2012 is reported. Assessment of sociodemographic and health status has been described.4 Participants
Corresponding Author: David R. Flum, MD, MPH, University of Washington, 1950 NE Pacific St, Box 356410, Seattle, WA 98195-6410 ([email protected]). Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Alfonso-Cristancho reports being an employee at GlaxoSmithKline and that his work there is not related to the research in this article. Dr Flum reports being an advisor for Pacira Pharmaceuticals, providing expert testimony for Surgical Consulting, and receiving travel expenses from Patient-Centered Outcomes Research Institute. No other disclosures were reported.
Author Manuscript
Role of the Funder/Sponsor: The NIDDK scientists contributed to the design and conduct of the study, which included collection and management of data. The project scientist from the NIDDK served as a member of the steering committee, along with the principal investigator from each clinical site and the data coordinating center. The data coordinating center housed all data during the study and performed data analyses according to a prespecified plan developed by the data coordinating center biostatistician and approved by the steering committee and independent data and safety monitoring board. The decision to publish was made by the Longitudinal Assessment of Bariatric Surgery-2 steering committee, with no restrictions imposed by the sponsor. As a coauthor, an NIDDK scientist contributed to the interpretation of the data and preparation, review, or approval of the manuscript. Author Contributions: Dr King had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Alfonso-Cristancho, Mitchell, Ramanathan, Sullivan, Flum. Acquisition, analysis, or interpretation of data: Alfonso-Cristancho, King, Mitchell, Belle, Flum. Drafting of the manuscript: Alfonso-Cristancho, King, Flum. Critical revision of the manuscript for important intellectual content: Alfonso-Cristancho, King, Mitchell, Ramanathan, Sullivan, Belle. Statistical analysis: King, Sullivan, Flum. Obtaining funding: Mitchell, Belle, Flum. Administrative, technical, or material support: Alfonso-Cristancho, Flum. Study supervision: Mitchell, Ramanathan, Belle.
Alfonso-Cristancho et al.
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completed the validated Work Productivity and Activity Impairment questionnaire5 presurgery and annually postsurgery. Work status among nonretirees and past-week work absenteeism (missed work due to health) and presenteeism (impaired work due to health) among employed participants were assessed. Mixed models were used to test change over time among those with baseline and at least 1 follow-up assessment, controlling for factors related to missing follow-up data as fixed effects (Table 1). Mixed models were used to examine the associations of surgical procedure and changes in weight, physical function and mental health, and comorbidity resolution, with postsurgery absenteeism and presenteeism in years 1, 2, and 3 controlling for baseline status. Adjusted relative risks and 95% CIs were reported. Analyses were conducted using SAS (SAS Institute), version 9.4. Two-sided P values less than .05 were considered statistically significant.
Results Author Manuscript
Of 2019 nonretired participants, 1773 (89%) had work factors data at 1 or more follow-up assessment(s) and were included in the analysis. Baseline median age was 45 years (interquartile range [IQR], 36–52); median body mass index (calculated as weight in kilograms divided by height in meters squared) was 46 (IQR, 42–52); 80% were women; 71% underwent Roux-en-Y gastric bypass; and 24% underwent a laparoscopic adjustable gastric band surgical procedure. Weight loss was 28% (95% CI, 27.4%–28.6%) at 3 years. Prevalence of employment or disability did not significantly change throughout follow-up, from presurgery values of 74.8% (95% CI, 72.8%–76.9%) for employment and 14.0% (95% CI, 12.5%–15.6%) for disability. However, unemployment increased from presurgery to year 3 (3.7%[95%CI, 2.9%– 4.5%] for presurgery vs 5.6% [95% CI, 4.4%–6.8%] for year 3 postsurgery, P = .02) (Table 1).
Author Manuscript
Of 1265 employed participants, 1092 (86%) were included in the work productivity sample. Prevalence of absenteeism was lower at year 1 (10.4% [95% CI, 8.4%–12.4%], P = .003) vs presurgery (15.2%[95%CI, 13.0%–17.4%]), but did not significantly differ from presurgery at year 2 or 3. Prevalence of presenteeism was lower than presurgery at all postsurgery times but increased from years 1 to 3 (62.8% at baseline; 31.9% at year 1; 35.6% at year 2; 41.0% at year 3).
Author Manuscript
Improvements in physical function and depressive symptoms were independently associated with lower risks of postsurgery absenteeism and presenteeism, whereas postsurgery initiation or continuation of psychiatric treatment vs no treatment presurgery or postsurgery was associated with higher risks (Table 2). Greater weight loss was independently associated with lower risk of postsurgery presenteeism only. Surgical procedure was not independently associated with either outcome.
Discussion In this large cohort of adults who underwent bariatric surgery, patients maintained working status and decreased impairment due to health while working. The small increase in unemployment by year 3 may reflect a secular trend in unemployment during the time of the study; the annual average rate of unemployment increased from 4.5% in 2007 to 8% in JAMA. Author manuscript; available in PMC 2017 October 18.
Alfonso-Cristancho et al.
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Author Manuscript
2012.6 The reduction in presenteeism following surgery may be explained by weight loss, improved physical function, or reduction in depressive symptoms. The increase in presenteeism between years 1 and 3 may reflect an adaptation to a new health state or deterioration of initial presurgery to postsurgery improvements. The limitations include the attrition rate, self-report data, restriction of the questionnaire to past week absenteeism and presenteeism at each visit, and lack of data on reasons for attrition or changes in employment status. Also, because the study did not have a parallel control group, findings cannot be attributed to the surgery itself.
Acknowledgments
Author Manuscript
Funding/Support: LABS-2 was a cooperative agreement funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); and by grants K24 DK080775 from NIDDK (Dr Subak), U01 DK066557 from the Data Coordinating Center, U01-DK66667 from Columbia University Medical Center (in collaboration with Cornell University Medical Center CTRC, grant UL1-RR024996), U01-DK66568 from University of Washington (in collaboration with CTRC, grant M01RR-00037), U01-DK66471 from the Neuropsychiatric Research Institute, U01-DK66526 from East Carolina University, U01-DK66585 from the University of Pittsburgh Medical Center (in collaboration with CTRC, grant UL1-RR024153), and U01-DK66555 from the Oregon Health & Science University.
References
Author Manuscript
1. Schmier JK, Jones ML, Halpern MT. Cost of obesity in the workplace. Scand J Work Environ Health. 2006; 32(1):5–11. [PubMed: 16539166] 2. Hammond RA, Levine R. The economic impact of obesity in the United States. Diabetes Metab Syndr Obes. 2010; 3:285–295. [PubMed: 21437097] 3. Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery. JAMA Surg. 2014; 149(3):275–287. [PubMed: 24352617] 4. Courcoulas AP, Christian NJ, Belle SH, et al. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013; 310(22):2416–2425. [PubMed: 24189773] 5. Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoeconomics. 1993; 4(5):353–365. [PubMed: 10146874] 6. Bureau of Labor Statistics. [Accessed August 30, 2015] Databases, tables, and calculators by subject. http://data.bls.gov/timeseries/LNS14000000
Author Manuscript JAMA. Author manuscript; available in PMC 2017 October 18.
Author Manuscript
Author Manuscript
Author Manuscript 14.0 (12.5–15.6)
Disabled
62.8 (59.7–65.9)
Presenteeism (any impairment while working due to health)
37.4 (37.2–37.7) 18.8 (18.5–19.1) 14.2 (13.8–14.6) 11.8 (11.4–12.2) 6.2 (5.8–6.6) 4.9 (4.5–5.4) 9.0 (8.6–9.4)
0
10
20
30
40
50
>50
Percentage reduction in productive work due to health problemse
15.2 (13.0–17.4)
Absenteeism (any missed work due to health)
Work Productivityd
3.7 (2.9–4.5)
74.8 (72.8–76.9)
Unemployed
Employed
Employment Statusc
Baseline
JAMA. Author manuscript; available in PMC 2017 October 18. 2.4 (2.0–2.7)
1.2 (0.9–1.6)
2.0 (1.6–2.4)
5.0 (4.6–5.4)
8.5 (8.2–8.9)
14.2 (13.8–14.6)
68.2 (68–68.5)
31.9 (28.8–35.1)
10.4 (8.4–12.4)
13.1 (11.6–14.7)
4.2 (3.3–5.1)
74.0 (71.8–76.2)
Year 1
6.5 (6.0–7.0)
2.3 (1.8–2.8)
2.3 (1.9–2.7)
4.2 (3.8–4.6)
7.1 (6.7–7.4)
15.1 (14.7–15.5)
64.9 (64.6–65.1)
35.6 (32.2–39.0)
11.6 (9.4–13.8)
13.4 (11.8–15.0)
4.9 (3.8–5.9)
74.9 (72.6–77.2)
Year 2
Model-Based Estimates, % (95% CI)a
5.3 (4.9–5.8)
2.4 (1.9–2.8)
3.9 (3.4–4.3)
5.3 (4.9–5.7)
12.0 (11.5–12.4)
13.4 (13.0–13.8)
59.5 (59.3–59.8)
41.0 (37.5–44.6)
13.8 (11.4–16.1)
14.1 (12.4–15.8)
5.6 (4.4–6.8)
73.0 (70.6–75.5)
Year 3
.17
.23
Overall P Value
JAMA. Author manuscript; available in PMC 2017 October 18. Published in final edited form as: JAMA. 2016 October 18; 316(15): 1595–1597. doi:10.1001/jama.2016.12040.
Longitudinal Evaluation of Work Status and Productivity After Bariatric Surgery
Author Manuscript
Rafael Alfonso-Cristancho, MD, PhD, MSc, Wendy C. King, PhD, James E. Mitchell, MD, Ramesh Ramanathan, MD, Sean D. Sullivan, PhD, Steven H. Belle, PhD, MScHyg, and David R. Flum, MD, MPH University of Washington, Seattle (Alfonso-Cristancho, Sullivan, Flum); University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania (King, Belle); Neuropsychiatric Research Institute, Fargo, North Dakota (Mitchell); University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Ramanathan) Obesity is associated with sick leave, disability, and work place injuries.1,2 Bariatric surgery is an effective treatment for patients with severe obesity.3,4 Evidence is limited regarding the relationship between bariatric surgery and work productivity. We assessed working status and productivity change in the first 3 years following surgery for severe obesity.
Methods Author Manuscript
Adults with severe obesity undergoing bariatric surgery were recruited (February 2005– February 2009) at 10 US centers for the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study.4 Each center obtained institutional review board approval; participants provided written consent. Three-year follow-up through October 2012 is reported. Assessment of sociodemographic and health status has been described.4 Participants
Corresponding Author: David R. Flum, MD, MPH, University of Washington, 1950 NE Pacific St, Box 356410, Seattle, WA 98195-6410 ([email protected]). Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Alfonso-Cristancho reports being an employee at GlaxoSmithKline and that his work there is not related to the research in this article. Dr Flum reports being an advisor for Pacira Pharmaceuticals, providing expert testimony for Surgical Consulting, and receiving travel expenses from Patient-Centered Outcomes Research Institute. No other disclosures were reported.
Author Manuscript
Role of the Funder/Sponsor: The NIDDK scientists contributed to the design and conduct of the study, which included collection and management of data. The project scientist from the NIDDK served as a member of the steering committee, along with the principal investigator from each clinical site and the data coordinating center. The data coordinating center housed all data during the study and performed data analyses according to a prespecified plan developed by the data coordinating center biostatistician and approved by the steering committee and independent data and safety monitoring board. The decision to publish was made by the Longitudinal Assessment of Bariatric Surgery-2 steering committee, with no restrictions imposed by the sponsor. As a coauthor, an NIDDK scientist contributed to the interpretation of the data and preparation, review, or approval of the manuscript. Author Contributions: Dr King had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Alfonso-Cristancho, Mitchell, Ramanathan, Sullivan, Flum. Acquisition, analysis, or interpretation of data: Alfonso-Cristancho, King, Mitchell, Belle, Flum. Drafting of the manuscript: Alfonso-Cristancho, King, Flum. Critical revision of the manuscript for important intellectual content: Alfonso-Cristancho, King, Mitchell, Ramanathan, Sullivan, Belle. Statistical analysis: King, Sullivan, Flum. Obtaining funding: Mitchell, Belle, Flum. Administrative, technical, or material support: Alfonso-Cristancho, Flum. Study supervision: Mitchell, Ramanathan, Belle.
Alfonso-Cristancho et al.
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completed the validated Work Productivity and Activity Impairment questionnaire5 presurgery and annually postsurgery. Work status among nonretirees and past-week work absenteeism (missed work due to health) and presenteeism (impaired work due to health) among employed participants were assessed. Mixed models were used to test change over time among those with baseline and at least 1 follow-up assessment, controlling for factors related to missing follow-up data as fixed effects (Table 1). Mixed models were used to examine the associations of surgical procedure and changes in weight, physical function and mental health, and comorbidity resolution, with postsurgery absenteeism and presenteeism in years 1, 2, and 3 controlling for baseline status. Adjusted relative risks and 95% CIs were reported. Analyses were conducted using SAS (SAS Institute), version 9.4. Two-sided P values less than .05 were considered statistically significant.
Results Author Manuscript
Of 2019 nonretired participants, 1773 (89%) had work factors data at 1 or more follow-up assessment(s) and were included in the analysis. Baseline median age was 45 years (interquartile range [IQR], 36–52); median body mass index (calculated as weight in kilograms divided by height in meters squared) was 46 (IQR, 42–52); 80% were women; 71% underwent Roux-en-Y gastric bypass; and 24% underwent a laparoscopic adjustable gastric band surgical procedure. Weight loss was 28% (95% CI, 27.4%–28.6%) at 3 years. Prevalence of employment or disability did not significantly change throughout follow-up, from presurgery values of 74.8% (95% CI, 72.8%–76.9%) for employment and 14.0% (95% CI, 12.5%–15.6%) for disability. However, unemployment increased from presurgery to year 3 (3.7%[95%CI, 2.9%– 4.5%] for presurgery vs 5.6% [95% CI, 4.4%–6.8%] for year 3 postsurgery, P = .02) (Table 1).
Author Manuscript
Of 1265 employed participants, 1092 (86%) were included in the work productivity sample. Prevalence of absenteeism was lower at year 1 (10.4% [95% CI, 8.4%–12.4%], P = .003) vs presurgery (15.2%[95%CI, 13.0%–17.4%]), but did not significantly differ from presurgery at year 2 or 3. Prevalence of presenteeism was lower than presurgery at all postsurgery times but increased from years 1 to 3 (62.8% at baseline; 31.9% at year 1; 35.6% at year 2; 41.0% at year 3).
Author Manuscript
Improvements in physical function and depressive symptoms were independently associated with lower risks of postsurgery absenteeism and presenteeism, whereas postsurgery initiation or continuation of psychiatric treatment vs no treatment presurgery or postsurgery was associated with higher risks (Table 2). Greater weight loss was independently associated with lower risk of postsurgery presenteeism only. Surgical procedure was not independently associated with either outcome.
Discussion In this large cohort of adults who underwent bariatric surgery, patients maintained working status and decreased impairment due to health while working. The small increase in unemployment by year 3 may reflect a secular trend in unemployment during the time of the study; the annual average rate of unemployment increased from 4.5% in 2007 to 8% in JAMA. Author manuscript; available in PMC 2017 October 18.
Alfonso-Cristancho et al.
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2012.6 The reduction in presenteeism following surgery may be explained by weight loss, improved physical function, or reduction in depressive symptoms. The increase in presenteeism between years 1 and 3 may reflect an adaptation to a new health state or deterioration of initial presurgery to postsurgery improvements. The limitations include the attrition rate, self-report data, restriction of the questionnaire to past week absenteeism and presenteeism at each visit, and lack of data on reasons for attrition or changes in employment status. Also, because the study did not have a parallel control group, findings cannot be attributed to the surgery itself.
Acknowledgments
Author Manuscript
Funding/Support: LABS-2 was a cooperative agreement funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); and by grants K24 DK080775 from NIDDK (Dr Subak), U01 DK066557 from the Data Coordinating Center, U01-DK66667 from Columbia University Medical Center (in collaboration with Cornell University Medical Center CTRC, grant UL1-RR024996), U01-DK66568 from University of Washington (in collaboration with CTRC, grant M01RR-00037), U01-DK66471 from the Neuropsychiatric Research Institute, U01-DK66526 from East Carolina University, U01-DK66585 from the University of Pittsburgh Medical Center (in collaboration with CTRC, grant UL1-RR024153), and U01-DK66555 from the Oregon Health & Science University.
References
Author Manuscript
1. Schmier JK, Jones ML, Halpern MT. Cost of obesity in the workplace. Scand J Work Environ Health. 2006; 32(1):5–11. [PubMed: 16539166] 2. Hammond RA, Levine R. The economic impact of obesity in the United States. Diabetes Metab Syndr Obes. 2010; 3:285–295. [PubMed: 21437097] 3. Chang SH, Stoll CR, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery. JAMA Surg. 2014; 149(3):275–287. [PubMed: 24352617] 4. Courcoulas AP, Christian NJ, Belle SH, et al. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013; 310(22):2416–2425. [PubMed: 24189773] 5. Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoeconomics. 1993; 4(5):353–365. [PubMed: 10146874] 6. Bureau of Labor Statistics. [Accessed August 30, 2015] Databases, tables, and calculators by subject. http://data.bls.gov/timeseries/LNS14000000
Author Manuscript JAMA. Author manuscript; available in PMC 2017 October 18.
Author Manuscript
Author Manuscript
Author Manuscript 14.0 (12.5–15.6)
Disabled
62.8 (59.7–65.9)
Presenteeism (any impairment while working due to health)
37.4 (37.2–37.7) 18.8 (18.5–19.1) 14.2 (13.8–14.6) 11.8 (11.4–12.2) 6.2 (5.8–6.6) 4.9 (4.5–5.4) 9.0 (8.6–9.4)
0
10
20
30
40
50
>50
Percentage reduction in productive work due to health problemse
15.2 (13.0–17.4)
Absenteeism (any missed work due to health)
Work Productivityd
3.7 (2.9–4.5)
74.8 (72.8–76.9)
Unemployed
Employed
Employment Statusc
Baseline
JAMA. Author manuscript; available in PMC 2017 October 18. 2.4 (2.0–2.7)
1.2 (0.9–1.6)
2.0 (1.6–2.4)
5.0 (4.6–5.4)
8.5 (8.2–8.9)
14.2 (13.8–14.6)
68.2 (68–68.5)
31.9 (28.8–35.1)
10.4 (8.4–12.4)
13.1 (11.6–14.7)
4.2 (3.3–5.1)
74.0 (71.8–76.2)
Year 1
6.5 (6.0–7.0)
2.3 (1.8–2.8)
2.3 (1.9–2.7)
4.2 (3.8–4.6)
7.1 (6.7–7.4)
15.1 (14.7–15.5)
64.9 (64.6–65.1)
35.6 (32.2–39.0)
11.6 (9.4–13.8)
13.4 (11.8–15.0)
4.9 (3.8–5.9)
74.9 (72.6–77.2)
Year 2
Model-Based Estimates, % (95% CI)a
5.3 (4.9–5.8)
2.4 (1.9–2.8)
3.9 (3.4–4.3)
5.3 (4.9–5.7)
12.0 (11.5–12.4)
13.4 (13.0–13.8)
59.5 (59.3–59.8)
41.0 (37.5–44.6)
13.8 (11.4–16.1)
14.1 (12.4–15.8)
5.6 (4.4–6.8)
73.0 (70.6–75.5)
Year 3
.17
.23
Overall P Value
